A 53-year-old man with a 15-year history as a baseball umpire experienced sharp left occipital pain after umpiring several games per week while wearing an umpire mask secured by a strap that put pressure on his nuchal ridge. This case highlights the importance of occupational history in making an appropriate clinical diagnosis and treatment plan.
Occipital Neuralgia: Anatomy and Introduction
The term neuralgia refers to a neuropathic pain that is felt along the path of a specific nerve and is often a result of injury to the nerve.1 The pain associated with neuralgia is variably described but most commonly is characterized as paroxysmal sharp, stabbing, piercing, or shock-like pain and is typically very severe and debilitating to the patient. It can also present more like a burning or throbbing sensation.
The most frequent neuralgias are occipital, trigeminal, and post-herpetic.2 Occipital neuralgia specifically refers to neuralgia that travels along the occipital nerve from the base of the skull to the vertex. Because of its location, it is frequently categorized as a headache.
The occipital nerve brings sensory information to the spinal cord at the level of C2 and C3 and has two main divisions. The lesser occipital nerve (lateral division) provides sensory afferents from the post-auricular area and the greater occipital nerve (medial division) provides sensory afferents from the skin overlying the posterior portion of the cranium (the occiput) starting inferiorly at the nuchal ridge and extending superiorly all the way to the vertex of the scalp, making it the largest solely afferent nerve in the human body.3,4
A 53-year-old male, in general good health, presented to our clinic complaining of left parietooccipital pain terminating at the vertex. The patient had spent the past 15 years as a baseball umpire. As an umpire, this patient worked 1 to 2 baseball games each weekday for a total of 4 to 6 hours in addition to 4 or 5 games every weekend for a total of approximately 9 hours. While working, he spends a majority of his time wearing a mask for the purpose of protection. The mask shields his face and extends to the posterior aspect of his scalp and upper neck where it is secured by a strap (see Figure 1).
The patient first noticed the pain about 4 years ago but only notices it while wearing the mask. He describes the pain as sharp, constant, and rated it a 7 out of 10 in terms of intensity. The patient stated that initially, removing the mask during breaks caused the pain to subside approximately 30 seconds after removal; however, by the time he was referred to us the pain was lasting for 2 to 3 minutes after removal of the mask.
The patient shares that the episodes of pain were followed by a mild, non-throbbing, tender headache, which he described a 3 out of 10 on a pain scale. Afraid that the problem might have been due to nerve damage or another serious condition which could potentially worsen, he mentioned the issue to his general practitioner, whom he sees on a regular basis. She then recommended that he see a neurologist.
Based on the clinical presentation, the patient was diagnosed with occipital neuralgia and treated with administration of a single dose of lidocaine plus dexamethasone injection subcutaneously at the nuchal ridge. In addition, the recommendation was made that he loosen the strap on his mask and place a soft pad between the strap and his nuchal ridge to relieve the pressure on the occipital nerve. The patient was pain-free from that point on, until just over 1 year later when he presented for a follow-up appointment.
At that time, he was experiencing a recurrence of the pain due to wearing a face mask that strapped around the back of the head on an airplane flight, which was required during the COVID-19 pandemic. The patient was once again treated with a lidocaine/dexamethasone injection and has been pain-free since.
Acute injuries to the occipital nerve are common and are usually idiopathic or the result of traumatic incidents. Other possible etiologies include occipital nerve entrapment, post-operative lesions, rheumatoid arthritis with subluxation affecting the atlanto-axial joint, C2 nerve root or dorsal root ganglion lesions such as tumors or vascular malformations, and infections.5 Chronic injuries such as the one seen in this case are rarer and tend to be caused by repetitive microtrauma to the nerve.6 Common causes of chronic damage to the occipital nerve typically involve prolonged periods of neck hyperextension.4.
Traditional Diagnosis and Treatment of Occipital Neuralgia
Upon suspicion that occipital neuralgia is the cause of a patient’s headache, one must be careful to confirm the diagnosis; in fact, occipital neuralgia is one of the most over-diagnosed headache conditions.4 Definitive diagnosis is made with an occipital nerve block using lidocaine or bupivacaine. If the pain is substantially reduced or eliminated upon performing a nerve block, the diagnosis of occipital neuralgia is confirmed.4
Once confirmed, there are several options for treatment. Steroid injections have been shown to temporarily relieve symptoms but in more severe cases, surgical procedures such as ablation, gamma knife resection, or microvascular decompression may be required.7,8
If the pain does not respond or responds minimally to an occipital nerve block, alternative diagnoses must be considered. Alternative diagnoses include tension headaches, which are commonly confused with occipital neuralgia, but do not respond to a single, local nerve block.9
In the presented case, the lidocaine/dexamethasone injection provided short-term relief while removal of the offending agent (umpire mask) was sufficient for long-term pain relief.
The Importance of Taking an Occupational History
This case highlights the importance of full history taking when presented with a new patient, and how certain aspects of a patient’s history can be a key distinguishing feature when formulating a differential and final diagnosis. In this instance, the patient was diagnosed with occipital neuralgia and appropriately treated so quickly because inquiries regarding the patient’s occupation were made by the neurologist while gathering the history of present illness.
According to the neurologist on the case, knowledge of the patient’s occupation as an umpire and a description of his attire while on duty were the most important considerations in making this particular diagnosis. Had the neurologist not inquired about the patient’s occupation, the proper diagnosis may not have been made as quickly and treatment could have been delayed.
Despite first being recommended by Bernardino Ramazzini in the year 1700 with his publication of the book De Morbis Artificum Diatriba (Treaty on Workers’ Diseases)that “what is your occupation?” should be added to the list of questions originally proposed by Hippocrates, not all physicians are compliant with this recommendation in the world of modern medicine.10-13
One perspective showed that completeness of a patient history is an even greater predictor of an accurate diagnosis than extensive physical examinations and laboratory tests.11 In a separate Turkish study, it was found that just 56.1% of physicians took an occupational history, with only 22.7% taking a detailed occupational history of all patients.12 Another study revealed that compared to age and gender, which 99% of physicians inquire about during the history-taking process, a mere 27.8% do the same for the patient’s occupation.13
Overall, the presented occipital neuralgia case provides an excellent example of the importance of taking a thorough medical history – including occupational history – and how responses to questions that are sometimes skipped during this process could in fact be an integral aspect of the critical complaint.